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July 10, 2018
Another Jump from a Hospital Window
Jumps and/or falls from hospital windows are rare events. Unfortunately, we do continue to see fatalities due to such jumps/falls and there are several themes and patterns common to such incidents. We’ve emphasized in several previous columns that there are important lessons learned from prior incidents. We discussed many of these in our Patient Safety Tips of the Week for April 12, 2016 “Falls from Hospital Windows” and February 14, 2017 “Yet More Jumps from Hospital Windows”.
Even though we lack details on many of these cases, there clearly is a pattern. Moreover, there are some surprisingly simple issues that are actually very good lessons learned. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically, he/she is confused or hallucinating. It’s not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room. Many such incidents occur when patients are housed on non-psychiatric units or general medical floors. Hospital beds are often used as “launch pads”.
A recent fatal jump from a hospital window illustrates many of these themes (Meehan 2018, WBAL 2018). The patient, a 47-year old man, apparently was on a “suicide watch” but was housed on a 10th floor general medical unit because of a high heart rate. He “refused to take his medicine and became aggressive.” He attempted to strike a staff member with a computer, according to a police report. He “then began to scoot his body closer to the end of the bed then [he] lunged toward the window.” He broke the window with his elbow and jumped out the opening, landing on the third-floor ledge of the hospital, according to police.
One obvious question always raised in such incidents is “why don’t you have windows that are not easily broken?” The hospital spokesperson in the above case said that the windows were within code for that type of room. But most general acute care hospitals have not installed the type of window used on behavioral health units that is not breakable or subject to manipulation. But perhaps it might be reasonable to designate one or two rooms on acute care floors for housing such patients deemed at risk and install such windows in those rooms. And, given that many such victims have been head trauma patients, perhaps it would be wise to install such windows on any acute head trauma units or other units dealing with TBI patients. But be wary that even windows you may consider “safe” may not be. At one hospital a male patient (no further details) removed a metal grill from a third floor window and fell out (Malloy 2016). The hospital subsequently checked the “safety restrictors” on all their windows.
So, what are the more subtle lessons learned? First is that several patients were able to stand up on the bed and “launch themselves” through the window from the bed. That implies a proximity of the bed to the window. In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we said one key lesson is to position the patient’s bed in the room at a reasonable distance away from the window so such “launches” are not possible. For example, if you have a high-risk patient in a typical double patient room, it may make sense to remove one bed and move the remaining bed to a more central position where it cannot be used to launch at the window.
Second, positioning of the observer may be important. The observer is usually positioned in the room on the side away from the window and near the door. We suspect that is intentional and may be a consideration for the safety of the observer plus it would allow the observer to easily yell for help if necessary. But that obviously needs to be rethought.
And some other less obvious equipment needs to be removed. That applies not only to the second bed but also to any object in the room that might be used to break the window, such as a chair or piece of medical equipment. In another recent case, a 70-year old man with a history of mental illness, drug and alcohol abuse, and was being evaluated when he picked up a chair and smashed the window in an 8th floor hospital room and jumped to his death (AP 2017, Valenzuela 2017). Care must be taken to make sure such objects are not in reach for a patient even for a very brief time. For example, if the observer needs to briefly leave the room perhaps their chair should be removed. In the case above, the patient apparently attempted to strike the observer with a computer.
But at a minimum, every room that is to be used for at-risk patients needs a thorough environemental assessment such as the VA’s Mental Health Environment of Care Checklist. Particularly in a room where medical equipment is being used there will be special dangers. For example, in a case discussed in our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” the patient’s oxygen had been discontinued but the mask, tubing, etc. were still in the room. These are objects that can be used by a patient to hang himself or otherwise injure himself. So make sure that medical equipment and supplies that are no longer needed are promptly removed from the room. The environmental assessment should also evaluate the immediate surroundings. For example, in that previous case there was a stairway exit 15 feet from the patient’s room with a door that was unlocked. (Note that we’ve discussed the VA’s Mental Health Environment of Care Checklist in several columns and will probably do another soon. Recent studies (Watts 2016, Mills 2016) have shown that it has been very successful in reducing suicides, perhaps more important than any other interventions.)
And one extremely important factor we’ve also discussed, not only in preventing falls/jumps from windows but also in preventing hospital suicides in general, is the importance of adequate training for the personnel designated as observers. Most people assigned as observers on med/surg floors have never worked in behavioral health units or even worked with behavioral health patients. Often they are not even healthcare personnel (some hospitals have utilized security personnel as observers) and may not have been adequately trained to recognize red flags or trained in de-escalation techniques.
Staff on med/surg units, ICU’s and rehab units need to be aware of risk factors for wandering, elopement, suicide or other impulsive behavior just as much as staff on behavioral health units do. Doing risk assessments and ensuring that staff caring for at-risk patients are adequately trained in dealing with such patients is important. When high-risk patients are identified it is also important to ensure they are not left alone in rooms with windows that can be opened (or broken) by patients and appropriate environmental assessments done to minimize the chance a patient may harm him/herself.
Lastly, don’t forget that intrahospital patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and wandering/elopement risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for wandering or elopement may wander off easily while waiting in the radiology suite if not appropriately supervised. We also hope that you’ve checked those bathrooms in radiology for loopables and other implements that might be used in a suicide attempt (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”).
See also our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention” for the Joint Commission’s recommendations for suicide prevention in general acute inpatient settings and emergency department settings.
So if we were doing the RCA (root cause analysis) on the above case, here are some of the questions we’d be asking:
Some of our prior columns on preventing hospital suicides:
References:
Meehan S, McDaniels AK. State investigating after man jumps from window to his death at Baltimore hospital. The Baltimore Sun 2018; June 13, 2018
http://www.baltimoresun.com/health/bs-md-ci-ummc-patient-death-20180613-story.html
WBAL. Regulators Reviewing Death Of Man Who Jumped From Baltimore Hospital Window. WBAL NewsRadio 2018; June 13, 2018
Valenzuela L. Elderly hospital patient smashes eighth-floor window and jumps to his death. Fresno Bee 2017; August 22, 2017
http://www.fresnobee.com/news/local/article168798102.html
AP (Associated Press). Man, 70, leaps to his death from eighth floor of Fresno hospital. LA Times 2017; August 23, 2017
http://www.latimes.com/local/lanow/la-me-ln-fatal-jump-20170823-story.html
Malloy T. Patient falls from window at Weston General Hospital after removing safety grill. SomersetLive 2016; August 12, 2016
VA Mental Health Environment of Care Checklist (MHEOCC).
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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July 17, 2018
OSA Screening in Stroke Patients
It’s well known that patients with obstructive sleep apnea (OSA) are at risk for cerebrovascular and cardiovascular events. But patients who suffer strokes are also particularly at high risk for OSA, and this has implications for both morbidity and mortality in these patients.
Sharma and Culebras (Sharma 2016) note that about 50-70% of patients with stroke have sleep-disordered breathing (SDB) as defined by AHI≥10/hour, with OSA being the most common pathology though some studies show that during the first 5 days poststroke central sleep apnea predominates. Males had a higher percentage of SDB (AHI>10) than females (65% vs 48%) and patients with recurrent strokes had higher percentage of SDB than patients with first stroke (74% vs 57%). Worsening of OSA may also be found after acute stroke due to impairment of respiratory muscle coordination and the presence of dysphagia may predict the development of OSA in patients with acute stroke. Traditional risk factors for OSA, such as a high BMI and large neck circumference, also predict OSA in acute stroke patients.
A recent meta-analysis (Seiler 2018) identified 54 studies performed in the acute phase after stroke (<1 month after stroke), 23 studies in the subacute phase (after 1–3 months) and 12 studies in the chronic phase (> 3 months). An AHI> 5/h and >30/h was found in 71% and 30% of patients, respectively. The severity of SDB was similar in all phases after stroke; however, only three studies assessed the same patients over time. The authors conclude that almost 1/3 of stroke patients present severe SDB, which appears to persist over time. Another recent study (Chakraborty 2017) found that the risk of OSA, as assessed by the STOP-BANG OSA risk tool, remains high at one month following discharge from hospitalization for acute stroke.
Of course, many of the risk factors for OSA are also risk factors for stroke. So, it should not be surprising that the occurrence of OSA is high in stroke patients. But it is also likely that mechanisms related to stroke may cause or accentuate OSA. For example, those strokes that lead to dysphagia or dysphonia have likely impacted pharyngeal musculature that is important in keeping the airway open. Patients with bilateral strokes are also more likely to have pharyngeal dysfunction (“pseudobulbar”), which may explain why some studies have shown OSA is more frequent in patients with recurrent strokes.
So, it is important to recognize which stroke patients are at risk for OSA acutely in the hospital because we may accentuate their risk with medications like opioids or sedative/hypnotic drugs. But OSA in the acute stroke patient may also lead to neurological deterioration, as has been noted in some observational studies. Davis and colleagues (Davis 2013) discussed some potential mechanisms of OSA contributing to poor neurologic recovery. These include direct effects of reduced cerebral blood flow and modulation of blood pressure and oxygen saturation associated with apneic episodes, resulting in further neurologic injury due to a compromise in perfusion to the ischemic penumbra.
But we need to recognize they may also be at risk for complications of OSA after discharge. A study recently presented at the SLEEP 2018 conference (the Annual Meeting of the Associated Professional Sleep Societies) illustrates how Hennepin County Medical Center used a quality improvement project to substantially increase recognition of OSA in their acute stroke or transient ischemic attack (TIA) patients (Metzler 2018). They implemented two sets of interventions (in July 2015 and March 2016), including an education session for resident physicians, an electronic stroke discharge note template, and email reminders. They then did retrospective chart review on ischemic stroke and TIA patients discharged over two consecutive months to collect OSA screening and referral data before and after each intervention, as well as a year later, to assess retention. The rate of OSA screening in ischemic stroke and TIA patients at discharge increased from baseline 2.4% in 2014 to 24.1% in 2015 following the first intervention. It further increased to 66.0% in 2016 after continued efforts for implementation. After reiteration, in 2017, the OSA screening rate improved to 69.4%. Moreover, all patients (100%) who screened positive had a sleep referral ordered at discharge. Physician survey before and after interventions found increase in self-reported screening rate (69% to 100%) and increase in satisfaction with the discharge template.
The Davis paper mentioned above (Davis 2013) summarized many of the studies assessing the impact of CPAP in acute stroke patients with OSA. Another recent systematic review and meta-analysis was done on randomized controlled trials (RCTs) examining the effectiveness of continuous positive airway pressure (CPAP) in stroke patients with sleep disordered breathing (SDB) (Brill 2018). The combined analysis of the neurofunctional scales (NIH Stroke Scale and Canadian Neurological Scale) showed an overall neurofunctional improvement with CPAP, but with a considerable heterogeneity across the studies. However, tolerability of CPAP was an issue. Mean CPAP use across the trials was only 4.53 hours per night and the odds ratio of dropping out with CPAP was 1.83. The authors conclude that CPAP use after stroke is acceptable once the treatment is tolerated and that CPAP might be beneficial for neurologic recovery, which justifies larger RCTs.
Many of you are already aware of a recent JAMA publication that questioned the ability of CPAP to reduce cardiovascular and cerebrovascular outcomes in patients with OSA (Yu 2017). They found no significant association of PAP with major adverse cardiovascular events (RR 0.77), cardiovascular death (RR 1.15), or all-cause death (RR 1.13). The same was true for ACS (acute coronary syndrome), stroke, and heart failure. They concluded that use of PAP, compared with no treatment or sham, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea. They acknowledge that there are other benefits of treatment with PAP for sleep apnea, but these findings do not support treatment with PAP with a goal of prevention of these outcomes. There have been numerous questions about the conclusions of that study, including whether compliance with PAP was adequate in the included studies and whether the power of the studies was adequate to make any firm conclusions. The study also did not specifically look at a subgroup of patients with acute stroke.
But both the Brill study and the Yu study leave us with the understanding that larger RCT’s, focusing on subsets such as the patient with acute stroke, are needed.
So, what should you be doing in the interim? We recommend that you consider all acute stroke patients at being at possible risk for OSA. We don’t recommend you do polysomnography on all such patients acutely, but you should do careful monitoring, especially if such patients are receiving medications that may accentuate OSA, such as opioids or sedative/hypnotics. And, given that the persistence of OSA after discharge remains high, we recommend that screening be done, with appropriate referral to sleep specialists after discharge.
Our prior columns on obstructive sleep apnea:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
March 26, 2013 “Failure to Recognize Sleep Apnea Before Surgery”
June 2013 “Anesthesia Choice for TJR in Sleep Apnea Patients”
September 24, 2013 “Perioperative Use of CPAP in OSA”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
March 3, 2015 “Factors Related to Postoperative Respiratory Depression”
August 18, 2015 “Missing Obstructive Sleep Apnea”
June 7, 2016 “CPAP for Hospitalized Patients at High Risk for OSA”
October 11, 2016 “New Guideline on Preop Screening and Assessment for OSA”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
References:
Sharma S, Culebras A. Sleep apnoea and stroke. Stroke and Vascular Neurology 2016;
https://svn.bmj.com/content/1/4/185
Seiler A, Camilo M, Korostovtseva L, et al. Prevalence of Sleep-Disordered Breathing After Stroke and Transitory Ischemic Attack: A Meta-Analysis. Exhibit 0464. SLEEP 2018; Annual Meeting of the Associated Sleep Societies; June 2-6; Baltimore.
Sleep 2018: 41(suppl_1): A175–A176
https://academic.oup.com/sleep/article-abstract/41/suppl_1/A175/4988501?redirectedFrom=fulltext
Chakraborty A, Tanielian M, Tzeng D, Doghramji K. 1149 Sleep Apnea is a Significant Co-Morbidity One Month Following Stroke. Sleep 2017: 40(suppl_1): A429
https://academic.oup.com/sleep/article/40/suppl_1/A429/3781212?searchresult=1
Davis AP, Billings ME, Longstreth WT, Khot SP. Early diagnosis and treatment of obstructive sleep apnea after stroke. Are we neglecting a modifiable stroke risk factor? Neurol Clin Pract. 2013; 3(3): 192-201
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721244/
Metzler A, Lindsay D, Irfan M. 0569 Screening for Obstructive Sleep Apnea in Patients with Ischemic Stroke and Transient Ischemic Attack. Sleep 2018: 41(suppl_1): A212
https://academic.oup.com/sleep/article-abstract/41/suppl_1/A212/4988606?redirectedFrom=fulltext
Brill AK, Horvath T, Seiler A, et al. CPAP as treatment of sleep apnea after stroke: a meta-analysis of randomized trials. Neurology 2018; 90(14): e1222-e1230
http://n.neurology.org/content/90/14/e1222.long
Yu J, Zhou Z, McEvoy D, et al. Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep ApneaA Systematic Review and Meta-analysis. JAMA 2017; 318(2): 156-166
https://jamanetwork.com/journals/jama/fullarticle/2643307?resultClick=1
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July 24, 2018
More on Speech Recognition Software Errors
Speech recognition software has the potential to significantly improve efficiencies in multiple healthcare settings. But in our October 4, 2011 Patient Safety Tip of the Week “Radiology Report Errors and Speech Recognition Software” we highlighted some of the problems associated with use of speech recognition software.
We certainly anticipated that improvements in speech recognition software technology would result in considerably reduced error rates since that time. But our December 2017 What's New in the Patient Safety World column “Speech Recognition Still Not Up to Snuff” found that both the efficiency and accuracy of speech recognition systems were not quite “up to snuff”.
In that column, we cited a study (Hodgson 2017) which compared the efficiency and safety of using speech recognition assisted clinical documentation within an electronic health record (EHR) system with use of keyboard and mouse in an emergency department setting. The researchers found that mean task completion times were 18.11% slower overall when using speech recognition compared to keyboard and mouse. For simple tasks speech recognition was 16.95% slower and for complex tasks 18.40% slower. Increased errors were observed with use of speech recognition (138 vs. 32 total errors, 75 vs. 9 errors for simple tasks, and 63 vs. 23 errors for complex tasks). The authors felt that some of the observed increase in errors may be due to suboptimal speech recognition to EHR integration and workflow. They concluded that improving system integration and workflow, as well as speech recognition accuracy and user-focused error correction strategies, may improve SR performance.
Another study of a random sample of 100 notes generated by emergency department physicians using computerized speech recognition (SR) technology also found substantial error rates in notes (Goss 2016). They found 1.3 errors per note, and 14.8% of errors were judged to be critical. Overall, 71% of notes contained errors, and 15% contained one or more critical errors. Annunciation errors (53.9%) were the most frequent, followed by deletions (18.0%), and added words (11.7%). Nonsense errors, homonyms and spelling errors were present in 10.9%, 4.7%, and 0.8% of notes, respectively.
Now, a new study by Zhou and colleagues (Zhou 2018) looked a random sample of operative notes, office notes, and discharge summaries from two hospital systems. They looked at the original speech recognition engine-generated document notes (SR), medical transcriptionist–edited documents, and physician’s signed notes (SN).
The overall error rate in speech recognition generated notes was 7.4% (i.e, 7.4 errors per 100 words). Overall, 96.3% of speech recognition engine-generated document notes (SR), 58.1% of medical transcriptionist–edited documents (MT), and 42.4% of physician’s signed notes (SN) contained errors. Discharge summaries had higher mean error rates than other types and surgeons’ notes had lower mean error rates.
Deletions (34.7%) were the most commonly identified error, followed by insertions (27.0%). Among errors at the SR, MT, and SN stages, 15.8%, 26.9%, and 25.9%, respectively, involved clinical information, and 5.7%, 8.9%, and 6.4%, respectively, were clinically significant. Clinically significant errors often involved medications or diagnoses.
Significantly, the error rate decreased from 7.4% to 0.4% after transcriptionist review and 0.3% in physicians’ signed notes. While stylistic changes or rearrangement of content were fairly commonly made in the editing process, in 27.2% the signing physician added information, and in 17.1% the physician deleted information.
The authors emphasize that this demonstrates the importance of manual review, quality assurance, and auditing.
But we would like to add we are appalled that we still continue to see documents in the EMR with the comment “dictated but not read”! Presumably, that is to make access to notes more timely. But, given the substantial frequency of errors in documents created via speech recognition software (or, for that matter, in documents produced by transcription of regular voice dictation), why would anyone risk the chance that an error could lead to patient harm? Even if those documents are later edited and amended to correct for any mistakes, there is always the possibility that an action may have already been based on the original (unedited) document.
Zhou and colleagues also found evidence suggesting some clinicians may not review their notes thoroughly, if they do so at all. They mention that transcriptionists typically mark portions of the transcription that are unintelligible in the original audio recording with blank spaces (eg, ??__??), which the physician is then expected to fill in. But they found 16 physician-signed notes that retained these marks. In 3 instances, the missing word was discovered to be clinically significant.
In our October 4, 2011 Patient Safety Tip of the Week “Radiology Report Errors and Speech Recognition Software” we asked how mistakes get overlooked when we review and edit our reports. The number one contributory factor is usually time pressure. In our haste to get the report done and the big queue of other reports to review, we simply don’t review and edit thoroughly. One of the early studies on report errors related to speech recognition systems (McGurk 2007) noted that such errors were more common in busy areas with high background noise or high workload environments.
But a second phenomenon happens as well. Our mind plays tricks on us and we often “see” what we think we should see. We show many examples during some of our presentations of orders or chart notes that have obvious omissions where the audience unconsciously “fills in the gaps” and thinks they saw something that wasn’t there (“of course they meant milligrams”). It is easy for us to do the same thing when we are reading our own reports. In addition, the “recency” phenomenon probably comes into play, where the physician perceives he/she sees what he/she just dictated. The Quint paper noted below (Quint 2008) suggests that mistakes like this may actually be more frequent the sooner you are reviewing your report. They even suggest that reviewing your report 6-24 hours after dictation rather than immediately may reduce the error rate.
Dictating in an environment with minimal background noise can help reduce errors. And McGurk et al note that use of “macros” for common standard phrases also reduces the error rates.
We’re willing to bet that most of you have no idea what your error rates are, regardless of whether you are using automated speech recognition software or traditional dictation transcription services.
Obviously, you need to include an audit of report errors as part of your QI process, not only for radiology but for any service that does reports of any kind, whether done by speech recognition software or more traditional transcription. While random selection of reports to review is a logical approach, there are other approaches that may make more sense. Part of the peer review process in radiology is to have radiologists review the images that a colleague had reported and see if the findings concur. One could certainly add checking for report errors as part of that process.
One older study (Quint 2008) found errors in 22% of radiology reports where radiologists estimated the error rates would be well less than 10% for the radiology department as a whole and even less frequent for themselves. In the Quint paper, the reports were analyzed as they came up as part of their weekly multidisciplinary cancer conference. Reviewing them is a fashion like this makes the review more convenient but also adds context to the review. One gets to see how the errors could potentially impact patient care adversely. We like that approach where such multidisciplinary conferences take place. It also tends to raise the awareness of the existence and scope of report errors among not only the people generating the reports, but also those reading the reports.
Integrating evaluation of your reports into your QI program, thus, is critical. So make sure you are determining your error rates in all your dictated reports (whether traditional or speech recognition format) and feeding back those error rates to the providers doing the reports. Such feedback to the providers doing the reports was important in reducing the error rates in the study by McGurk et al.
Some of our past columns relating to speech recognition software:
References:
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the electronic health record. Journal of the American Medical Informatics Association 2017; 24960; 1127-1133
Goss FR, Zhou L, Weiner SG. Incidence of speech recognition errors in the emergency department. International Journal of Medical Informatics 2016; 93: 70-73
http://www.ijmijournal.com/article/S1386-5056(16)30090-9/abstract
Zhou L, Blackley SV, Kowalski L, et al. Analysis of Errors in Dictated Clinical Documents Assisted by Speech Recognition Software and Professional Transcriptionists. JAMA Network Open 2018; 1(3): e180530 July 6, 2018
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687052
McGurk S, Brauer K, MacFarlane TV, Duncan KA. The effect of voice recognition software on comparative error rates in radiology reports. Br. J. Radiol. 2008; 81: 767-770
Quint LE, Quint DJ, Myles JD. Frequency and Spectrum of Errors in Final Radiology Reports Generated With Automatic Speech Recognition Technology. Journal of the American College of Radiology 2008; 5(12): 1196-1199
http://www.jacr.org/article/S1546-1440%2808%2900361-X/abstract
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July 31, 2018
Surgery and the Opioid-Tolerant Patient
We’ve done a lot of columns about opioid-induced respiratory depression in the perioperative period (see the full list of columns below). But one topic we’ve not done enough on is how to manage the opioid-tolerant patient in the perioperative period. More and more patients are coming to surgery alreay taking opioids, often in high doses, and present unique challenges.
An observational study of patients undergoing surgery at a tertiary care academic medical center (Hilliard 2018) identified preoperative opioid use in 23.1%. And the most common opioids used were hydrocodone bitartrate (59.4%), tramadol hydrochloride (21.2%), and oxycodone hydrochloride (18.3%). Preoperative opioid use was most commonly reported by patients undergoing orthopedic (65.1%) and neurosurgical spinal (55.1%) procedures and least common among patients undergoing thoracic procedures (15.7%). Factores independently associated with preoperative opioid use were age 31 to 40 years, former or current tobacco use, illicit drug use, higher pain severity, depression, higher Fibromyalgia Survey scores, lower life satisfaction, and more medical comorbidities.
In addition, in the perioperative period, higher opioid prescription is associated with an increase in most postoperative complications, with the strongest effect observed in thromboembolic, infectious and gastrointestinal complications, cost, and length of stay (Cozowicz 2017). The increase in complication risk occurred in a stepwise fashion, suggesting a dose-response gradient.
And it is also known that pre-operative opioid use is a strong predictor of chronic post-operative opioid use (Goesling 2016).
Not only do such patients present the need for careful monitoring for opioid-induced respiratory depression and opioid side effects, but we must also pay attention to adequate pain management and the risk of opioid withdrawal syndromes, often while dealing with the complexities of opioid dose conversion.
Fortunately, the BJA Education series recently had an excellent review by Simpson and Jackson on the perioperative management of the opioid-tolerant patient (Simpson 2017). They note goals of the pain management plan for opioid tolerant in the perioperative period are:
They note the risk of an adverse event is higher among patients prescribed >50 mg oral morphine equivalent per day. Patients receiving > 50 or >100 mg per day have 3.7- and 8.9-fold increases, respectively, in risk of an overdose compared with patients receiving doses <20 mg per day.
Below are some of the recommendations from Simpson and Jackson:
Multimodal Opioid-Sparing Techniques
Regularly prescribed paracetamol, non-steroidal anti-inflammatory drugs, or COX-2’s should be used unless contraindicated and local anaesthetic techniques including wound infiltration, regional, or neuroaxial block should be used where possible. They also discuss potential roles for ketamine, gabapentinoids, and IV lidocaine infusions. (But see our November 2017 What's New in the Patient Safety World column “Bad Combination: Gabapentin and Opioids” regarding potential dangerous interactions between gabapentinoids and opioids.)
Prevention of Withdrawal
The authors note that opioid withdrawal symptoms can occur if a drug is suddenly stopped, reversed, reduced too quickly, or fails to reach its intended site of action. They recommended that the patient's baseline opioid (usually a sustained-release form) be continued in the postoperative period and that acute post-surgical pain is managed with the addition of appropriate doses of IR opioids. They recommend that transdermal opioids be continued at their baseline doses but caution about several issues with transdermal patches. Patch positioning may be important. For example, direct heat applied to the patch via perioperative warming devices may enhance drug administration, whereas the use of a patch over an area of poor-perfusion or reduced temperature can reduce drug delivery.
They note that many patients may be unable to take oral opioids post-operatively and provide a table for converting to an equivalent IV.dose of morphine and/or use of PCA pumps.
They have a good discussion about how to calculate the total opioid dose when additional opioids are needed post-op and a good discussion about opioid “rotation”. They provide opioid equivalence/conversion tables to assist with this.
Converting from IV back to Oral Opioid
Converting from IV back to an oral opioid is also potentially complex and they provide guidelines for this.
Opioid Tolerance/Opioid-Induced Hyperalgesia
They have an excellent discussion about opioid tolerance and the opioid-induced hyperalgesia phenomenon, noting the two may be difficult to distinguish from each other or from progression of the underlying condition.
Substance abuse and substitution therapy
They also have a discussion about the roles of drugs like methadone, buprenorphine, and naltrexone in substance abuse therapy.
Discharge Plan
They stress it is of paramount importance to formulate and communicate a plan for onward-care after discharge from hospital. This may typically involve a discussion with the outpatient physician who will be primarily managing the patient and a carefully documented discharge letter highlighting the importance of reducing and stopping treatment if it is ineffective or no longer required. Inclusion of a pharmacist may also be worthwhile.
The only thing missing from the Simpson article is a section on monitoring. But you can go to our numerous columns on perioperative monitoring of patients on opioids listed below. Obviously, all such patients merit full monitoring, including continuous pulse oximetry and capnography.
In an editorial accompanying the Hilliard study, Ashburn and Fleisher (Ashburn 2018) note the importance of perioperative multimodal pain care, using regional anesthesia and non-opioid pain medications, avoidance of opioid overprescribing, and prompt referral to specialty care when problems associated with opioid use occur after surgery.
In our multiple columns on hydromorphone issues (see, for example, our June 20, 2017 Patient Safety Tip of the Week “Dilaudid Dangers #4”) we’ve made a case that prescription of certain opioids in the hospital should be done under supervision of pain management services. The same arguments apply to prescription of a whole host of extended release or long-acting opioid formulations. However, not all hospitals are fortunate enough to have such services or even have professional staff who are expert in pain management.
The VA healthcare system has some interesting tools to help in management of patients on chronic opioid therapy (Raghunathan 2017). One is the Opioid Therapy Risk Report (OTRR), a patient database that contains details regarding opioid prescriptions (e.g., duration, amount and type over the past 12 months), pain scores over the past 12 months and most recent urine drug test results. It also notes certain factors that increase risks, such as concomitant use of benzodiazepines, diagnoses of Obstructive Sleep Apnea (OSA), and mental illnesses like depression, PTSD or substance use and whether naloxone has been dispensed. They also have a tool called STORM (Stratification Tools for Opioid Risk Mitigation), which apparently had been developed for use in behavioral health but is being adapted for use in surgery. The STORM surgery tool aims to better coordinate medication handoffs by adding additional risk estimates tailored to the perioperative environment and patient populations, including risk of prolonged opioid use after surgery.
Many states, such as New York, have databases containing information regarding opioid prescriptions for patients that should be accessed by any physician considering prescribing an opioid for a patient. But such databases currently lack the other vital integrated medical data found in the comprehensive VA database. But databases with information similar to the VA’s OTRR database might be available through large medical systems or insurers. It clearly would be valuable to have such information available prior to surgery so that rational plans could be developed for managing opioid-tolerant patients before, during, and after surgery.
And, of course, there has been a focus on reducing the likelihood of persistent opioid use following surgery, even for patients who were opioid-naïve prior to surgery. A recent study (Brummett 2017) showed that new persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. The rates of new persistent opioid use were similar between the 2 groups, ranging from 5.9% to 6.5%. The authors propose that new persistent opioid use should be considered a surgical complication that is both common and previously underappreciated.
One factor contributing to the opioid epidemic has been prescribing amounts of opioids (i.e. the number of pills dispensed) far in excess of what is actually needed by patients. In another recent study, Brat and colleagues (Brat 2018) identified opioid-naive patients undergoing surgery from a linked medical and pharmacy administrative database. They found that each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. You’ll recall that several states have been addressing the opioid epidemic by limiting initial prescriptions for opioids to very short timeframes (for example, 7 days). One recent study showed that lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures (Chin 2018).
Attempts have been made to develop guidelines for the optimal amount and duration of opioid prescriptions following surgery. Scully et al. analyzed prescription and refill data on patients in the Department of Defense Military Health System Data Repository who had undergone one of 8 common surgeries (Scully 2018). They then did modeling and found the patterns varied based upon the nature of the surgery. They suggested that the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.
But those suggestions were for opioid-naïve patients. In a comment on the Scully study, Hah and Hernandez-Boussard (Hah 2018) note that 41.7% of patients in that data set were excluded because they had received a prescription for opioids within the 6 months prior to surgery. That, of course, highlights the problem of trying to fit all post-op patients into nice categories. There are no good current guidelines for discharge opioid prescribing in patients who had been taking opioids prior to their surgery.
In an ISMP Canada article primarily on safe storage and disposal of medications (ISMP Canada 2018) we came across a useful information tool for patients receiving opioids after surgery, developed by multiple Canadian organizations participating in an opioid safety collaborative.
We hope that you’ll also read some of our prior columns on opioid safety in the perioperative period and those on other safety issues associated with some specific opioid agents.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Our prior articles pertaining to long-acting and/or extended release preparations of opioids:
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
Some of our other Patient Safety Tips of the Week regarding fentanyl and fentanyl patches:
References:
Hilliard PE, Waljee J, Moser S, et al. Prevalence of Preoperative Opioid Use and Characteristics Associated With Opioid Use Among Patients Presenting for Surgery. JAMA Surg 2018; Published online July 11, 2018
Cozowicz C, Olson A, Poeran J, et al. Opioid prescription levels and postoperative outcomes in orthopedic surgery. Pain 2017; 158(12): 2422-2430
Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain 2016; 157(6): 1259-1265
Simpson GK, Jackson M. Perioperative Management of Opioid-tolerant Patients. BJA Education 2017; 17(4): 124-128
https://academic.oup.com/bjaed/article-abstract/17/4/124/2454796
Ashburn MA, Fleisher LA. Perioperative Opioid Management—An Opportunity to Put the Genie Back Into the Bottle. JAMA Surg 2018; Published online July 11, 2018
Raghunathan K, Mudumbai S, Barbeito A, Trafton J. Tools to Reduce Perioperative Opioid-Related Risks. TIPS Topics in Patient Safety® 2017; 17(2): 7-8
https://www.patientsafety.va.gov/docs/TIPS/2017_April_May_June_TIPS_Internet_FINAL.pdf#page=7
Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg 2017; 152(6): e170504
Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360: j5790
http://www.bmj.com/content/360/bmj.j5790
Chin AS, Jean RA, Hoag JR, et al. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surg 2018; Published online July 18, 2018
Scully RE, Schoenfeld AJ, Jiang W, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surg 2018; 153(1): 37-43
https://jamanetwork.com/journals/jamasurgery/article-abstract/2654949
Hah J, Hernandez-Boussard T. Defining Postoperative Opioid Needs Among Preoperative Opioid Users. JAMA Surg 2018; 153(7): 689-690
ISMP Canada. Safe Storage and Disposal of Medications. ISMP Canada Safety Bulletin 2018; 18(5): 1-4 June 27, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-06-StorageDisposal.pdf
information tool for patients prescribed opioids after surgery
https://www.ismp-canada.org/download/OpioidStewardship/OpioidsAfterSurgery-EN.pdf
Print “Surgery and the Opioid-Tolerant Patient”
August 14, 2018
ISMP Canada's Updated "Do Not Use" Abbreviation List
ISMP Canada recently updated its “Do Not Use” abbreviation list after doing an analysis of use of abbreviations in healthcare settings (ISMP Canada 2018). We like the basic tenet they use about abbreviations: “…abbreviations, as well as symbols and dose designations, are only helpful when their intended meaning is fully understood by all persons who will be deciphering the information and when there is no potential for misinterpretation.” ISMP Canada also stresses that inappropriate use of abbreviations can be particularly hazardous at transitions of care (ISMP Canada 2017).
The report particularly highlights problematic use of route designations such as SL, SQ, and SC, and use of the abbreviation “d” to represent days or doses, and use of the ampersand symbol (&) to denote the word “and”.
SL (intended to mean sublingual), SQ (intended to mean subcutaneous), and SC (also intended to mean subcutaneous) can easily be confused with each other. In addition, “SQ” is sometimes misinterpreted as a “5 every”.
The abbreviation “d” can be interpreted as either days or doses. An example given was the order “Lactulose 15 mL po bid x 2d”. That order was intended to mean “for a duration of 2 doses” but was mistaken as “for a duration of 2 days”.
They also note some abbreviations that we, quite frankly, have not seen used. These include use of fractions meant to convey information about duration or frequency. Examples given are #/24, #/7, #/52 (denoting numbers per 24 hours, 7 days, and 52 weeks, respectively). Another example was a direction for tapering a corticosteroid written as “2/7” and then “1/7”. The intended meaning was that the prescribed dose be given “for2 days” and then “for 1 day”, but the instructions were interpreted to mean treatment “for 2 weeks” and then “for 1 week”, resulting in the patient receiving a longer duration of therapy than was intended and experienced adverse effects for which admission to hospital was required.
There is some good news, however, about fewer dangerous abbreviations with the electronic medical record. The current ISMP Canada bulletin notes that a recent Canadian hospital audit found the rates of dangerous abbreviation use on electronic medication orders was significantly less than on paper orders (0.4% vs. 24.1%, respectively). That is reassuring because during one quality improvement implementation we found numerous dangerous abbreviations in order entry screens and standardized order sets and some third party vendor modules in an EHR (see our July 14, 2009 Patient Safety Tip of the Week “Is Your “Do Not Use” Abbreviations List Adequate?”). Dangerous abbreviations also have a nasty habit of showing up in texted information and are one of our many arguments that orders should never be texted.
The ISMP Canada list (ISMP Canada 2018b) and the even more comprehensive ISMP (US) list (ISMP 2017) are considerably longer than Joint Commission’s list of dangerous abbreviations. In that July 14, 2009 Patient Safety Tip of the Week “Is Your “Do Not Use” Abbreviations List Adequate?”) we discussed that many hospitals only adhere to the shorter Joint Commission “Do Not Use” abbreviation list. In reviewing a hospital’s “Do Not Use” abbreviation list for potential expansion, we found about 4% of total orders had an abbreviation that appears on the ISMP list. However, about one in every seven verbal or telephone orders contained such an abbreviation.
We take heart that the detrimental effect of dangerous abbreviations has likely been mitigated somewhat as we’ve transitioned from handwritten orders to electronically formatted orders. In fact, some of the old ISMP samples of dangerous handwritten abbreviations seem anachronistic when we show them in presentations. But they’ve been replaced by the new kid on the block: texting. In our several columns (listed below) about the dangers of texting orders, we cited use of dangerous abbreviations as one example. In our January 30, 2018 Patient Safety Tip of the Week “Texting Errors Revealed” we noted common texting abbreviations are a threat. We’ve spoken before about the example of a texted “2day” (meaning “today”) getting misinterpreted as “two daily” (ISMP 2009). ISMP provided some other examples of errors related to texted abbreviations last summer (ISMP 2017b) and the latest ISMP survey (ISMP 2017a) uncovered a new one: the text abbreviation “BTW” (meaning “by the way”) was misinterpreted as meaning “twice daily”. And, while we were happy The Joint Commission saw the light and did not reverse its ban on texting orders, the above mentioned ISMP survey notes that the practice probably continues to exist to some degree despite hospital policies banning it.
We recommend healthcare organizations use the ISMP (US) list and perform due diligence in purging such abbreviations that might be buried in their EHR’s in order sets (particularly old ones or “personalized” ones if you allow them) or in third party vendor software modules. Every organization also needs to periodically audit records to see how often dangerous abbreviations continue to be used. You may be surprised at what you find. We also suggest you look at the recommendations in our December 22, 2015 Patient Safety Tip of the Week “The Alberta Abbreviation Safety Toolkit”.
Some of our previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “The Alberta Abbreviation Safety Toolkit”
See our other Patient Safety Tip of the Week columns dealing with texting:
References:
ISMP Canada. Rearming the “Do Not Use: Dangerous Abbreviations, Symbols
and Dose Designations” List. ISMP Canada Safety Bulletin 2018; 18(4): May 30, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-05-DoNotUseList.pdf
ISMP Canada’s “Do Not Use Dangerous Abbreviations, Symbols and Dose Designations” list. Original 2006, reaffirmed 2018.
https://www.ismp-canada.org/download/ISMPC_List_of_Dangerous_Abbreviations.pdf
ISMP Canada. Errors Associated with Hospital Discharge Prescriptions: A Multi-Incident Analysis. ISMP Canada Safety Bulletin 2017; 17(1): 1-5 January 31, 2017
ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. October 2017
https://www.ismp.org/recommendations/error-prone-abbreviations-list
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
https://www.ismp.org/newsletters/acutecare/archives/Feb09.asp
ISMP (Institute for Safe Medication Practices). ISMP survey shows provider text messaging often runs afoul of patient safety. ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017
ISMP (Institute for Safe Medication Practices). The texting debate: Beneficial means of communication or safety and security risk? ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017
Print “ISMP Canada’s Updated “Do Not Use” Abbreviation List”
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
An 81 year old SNF patient with a left hemiparesis secondary to an old stroke, muscle weakness, difficulty swallowing, difficulty walking, and impaired cognition was briefly left unattended on a commode and fell (CDPH 2018). Blood was noted coming from skin adjacent to her left eye. She was sent to a local hospital emergency department, where a CT scan of the head was said to show only changes related to the prior stroke and no acute findings. A laceration adjacent to the left eye was sutured and she was returned to the SNF. The report does not provide a full medication list but does note the patient was on Eliquis (the novel oral anticoagulant apixaban). The report also does not provide measures of her renal function or other lab data. Two days later she was noted to have a mental status that was altered compared to her baseline and she was sent back to the hospital, where a CT scan showed a 1.2 cm left-sided subdural hematoma with mass effect that had developed since the prior CT scan. It was decided to provide only comfort care and she died 5 days later.
This case illustrates an issue that has led to considerable debate - what to do with the anticoagulated patient who suffers minor head trauma and has an initial negative CT scan. The multiple good clinical decision support tools we have for deciding about CT scans in patients with minor head trauma (see our March 2017 What's New in the Patient Safety World column “Update on CT Scanning after Minor Head Trauma”) do not apply to patients on anticoagulants.
In our July 17, 2007 Patient Safety Tip of the Week “Falls in Patients on Coumadin or Heparin or Other Anticoagulants” we highlighted the problem of delayed hemorrhage after falls in patients on anticoagulants. Specifically, we discussed the patient who falls and has minor head trauma, has a negative CT scan of the head, and then later develops a subdural hematoma (or other intracranial hemorrhage). The example we gave was an elderly patient with a cardiac condition on full-dose heparinization while an inpatient who had an unwitnessed fall in the hospital one evening. He did not lose consciousness and was alert and fully oriented when the medical resident examined him after the fall. He had a mild ecchymosis on his right forehead but no focal neurological signs and no evidence of trauma elsewhere on the body. Because the patient was fully anticoagulated, the resident ordered an emergency head CT scan, which was normal. No changes were made in his heparin regimen. The following morning the patient was more somnolent than usual and a repeat CT scan showed a sizeable subdural hematoma that required surgical evacuation.
Several of our subsequent columns presented literature reviews showing that the occurrence of delayed subdural hematoma requiring intervention is very rare in anticoagulated patients having an initial negative CT scan. They note that doing delayed scans is costly, both in terms of the cost of a second scan and the cost of keeping the patient under observation for a longer period of time.
Since our last update in 2014 (see our July 8, 2014 Patient Safety Tip of the Week “Update: Minor Head Trauma in the Anticoagulated Patient”) there have been several more articles on the issue.
A study (McCammack 2015) showed that use of a routine six-hour follow-up head CT in patients on anticoagulant/antiplatelet treatment after mild TBI is of extremely low yield, with delayed ICH occurring in only one of 134 patients (0.7% incidence) in the study population. Furthermore, the one case of delayed ICH required no intervention and resulted in no sustained deviation from the patient’s baseline.
Another study evaluated the utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in patients with mild head trauma (Glasgow Coma Scale 13–15) taking oral anticoagulants (Campiglio 2017). Of 344 patients, 337 (97.9%) had a negative CT1. CT2 was performed on 284 of the 337 patients with a negative CT1 and was positive in 4 patients (1.4%), but none of the patients developed concomitant neurologic worsening or required neurosurgery. The authors conclude that systematic routine use of a second CT scan in mild head trauma in patients taking anticoagulants is expensive and clinically unnecessary.
A systematic review and meta-analysis (Chauny 2016) reviewed studies estimating the risk of delayed intracranial hemorrhage 24 h after head trauma in patients anticoagulated with vitamin K antagonist and normal initial CT scan. Seven publications were identified encompassing 1,594 patients who had a repeat CT scan after a normal first head scan. For these patients, the pooled estimate of the incidence of intracranial hemorrhage on the second CT scan 24 h later was 0.60% (95% CI 0–1.2%) and the risk of neurosurgical intervention or death was only 0.13%. They concluded that, in most situations, a repeat CT scan in the emergency department 24 h later is not necessary if the first CT scan is normal. But the authors note that special care may be required for patients with serious mechanism of injury, patients showing signs of neurologic deterioration, and patients presenting with excessive anticoagulation or receiving antiplatelet co-medication.
A retrospective multicenter study from the Netherlands (Verschoof 2018) looked at patients with mild traumatic brain injury (mTBI) on anticoagulants who had an INR ≥ 1.7 and reportedly normal cranial CT obtained within 24 h after trauma. Of 905 patients, four deteriorated neurological within 24 hours and 5 others deteriorated on days 2, 18, 22, 36 and 52, respectively. In six patients, including all four that developed symptoms within 24 h, intracranial hemorrhage (ICH) was found upon reevaluation of initial imaging. So no patient actually developed delayed ICH within 24 hours. They also did a meta-analysis of 9 studies with data from 2885 patients. The estimated pooled proportion of symptomatic delayed ICH or delayed diagnosis of ICH within 24 h was 0.2%. They concluded that delayed diagnosis of ICH within 24 h is very rare in patients on anticoagulants with minor head trauma after reportedly normal initial CT and that routine hospitalization of these patients seems unwarranted when the initial cranial CT is scrupulously evaluated.
And a just published prospective observational study also suggests that routine observation and serial cranial computed tomography may not be necessary in these patients (Cheonoweth 2018). The authors looked at patients 55 years and older who had blunt head trauma and were seen emergently at 11 hospitals in northern California. Median age was 75 years and 40% of the total 859 patients enrolled in the study were taking anticoagulant and antiplatelet medications. Only 3 patients (and only one on warfarin alone) suffered delayed traumatic intracranial hemorrhage. Thus, the overall rate of delayed intracranial hemorrhage in patients on warfarin alone was 1.3%. The findings of this study suggest that routine observation and serial cranial computed tomography may not be necessary in these patients. It was also notable that 2 of the 3 delayed hemorrhages occurred 3 and 5 days after the head trauma. Those guidelines that recommend a repeat CT scan usually recommend it within 24 hours of the trauma, so even these delayed hemorrhages would have been missed. The study also only analyzed patients who had been transported to ER’s via EMS, so these likely even overestimated the risk of delayed intracranial hemorrhage in patients with minor head trauma.
In a study in a different population, patients with head trauma who had intracranial hemorrhage on an initial CT scan, Bellal et al. (Bellal 2018) found a threefold increase in the rate of worsening repeat head CT in patients on warfarin or antiplatelet agents compared to those not on such agents (26 vs 9%).
A prospective study of patients on anticoagulants or antiplatelet medications who had a ground-level fall with head trauma found the incidence of traumatic intracranial hemorrhage (tICH) was low in both groups (Ganetsky 2017). Interestingly, there was no statistical difference in rate of tICH between antiplatelet and anticoagulants, which is unanticipated and counterintuitive as most literature and teaching suggests a higher rate with anticoagulants. The authors suggest a larger data set is needed to determine if small differences between the groups exist.
So, the bulk of evidence strongly suggests that delayed development of intracranial hemorrhage after minor head trauma in patients on anticoagulants when initial CT scan is negative is indeed rare. And those guidelines that would suggest observation of the patient for 24 hours and then repeat CT scan would probably lead to many unnecessary hospital stays and CT scans and excessive costs.
But, once again, we emphasize the need for good instructions for the patient and, more importantly, for the caregivers when such patients are to be discharged. The major initial symptoms and signs of subdural hematomas are usually related to changes in the level of consciousness or cognition rather than “focal” neurological signs. These signs can be subtle. That’s why we previously warned in our July 17, 2007 Patient Safety Tip of the Week “Falls in Patients on Coumadin or Heparin or Other Anticoagulants” that the “neuro checks” must be carried out as ordered (whether the patient is under hospital observation or being observed by family or others at home). We’ve often seen in that past that there is a tendency for “neuro checks” to be overlooked when the patient is asleep – which is exactly when neuro checks are most important! And telephone follow-up the next day may be an effective strategy.
So, your decision not to utilize 24-hour observation and repeat CT scan in anticoagulated patients with a normal initial CT scan might be backed up by statistics, but you need to ensure they will be sent to a setting where any change in level of arousal or cognitive function would be promptly recognized. The patient with a supratherapeutic INR or concomitant antiplatelet therapy or no reliable caregiver who can observe them at home would be one you might consider for 24 hour hospital observation and repeat CT scan in 24 hours. Of course, now that so many patients are on NOAC’s (novel oral anticoagulants) rather than vitamin K antagonists like warfarin, we don’t have good lab measures of their degree of anticoagulation to guide us.
However, as in our June 5, 2012 Patient Safety Tip of the Week “Minor Head Trauma in the Anticoagulated Patient” the optimal timing of CT scans remains unknown. We’d like to see a study that looks at the timing of initial CT scans that show intracranial bleeding in anticoagulated patients relative to the time of their head trauma. We suspect that the optimal approach may lay somewhere in between the above options. That might show that the initial CT scan might be delayed in an anticoagulated patient with minor head trauma who is alert without focal neurological signs or altered level of arousal or altered cognition. For example, you might opt to keep the patient on observation for 6-8 hours and then perform the initial CT scan.
We wish we had the final answer for you now. But we don’t. The literature would certainly suggest that, on the whole, we would waste a lot of resources if we put all such patients on 24-hour observation and did 2 CT scans (the initial one and then a repeat at 24 hours). But then you come across cases like the one in today’s column and the one in our July 17, 2007 Patient Safety Tip of the Week “Falls in Patients on Coumadin or Heparin or Other Anticoagulants” and it makes you think twice.
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
March 2010 “CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma”
November 23, 2010 “Focus on Cumulative Radiation Exposure”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
January 2017 “Still Too Many CT Scans for Pediatric Appendicitis”
March 2017 “Update on CT Scanning after Minor Head Trauma”
September 2017 “Clinical Decision Rule Success”
Some of our previous columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
References:
CDPH (California Department of Public Health). Intake # CA00551075, CA00550513. CPDH 2018; January 19, 2018
McCammack KC, Sadler CA, Guo Y, et al. Routine Repeat Head CT may not be Indicated in Patients on Anticoagulant/Antiplatelet Therapy Following Mild Traumatic Brain Injury. Western Journal of Emergency Medicine 2015; 16(1): 43-49
Campiglio L, Bianchi F, Cattalini C, et al. Mild brain injury and anticoagulants. Less is enough. Neurology Clinical Practice 2017; 7(4) August 01, 2017
http://cp.neurology.org/content/7/4/296
Chauny J-M, Marquis M, Bernard F, et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Emerg Med 2016; 51(5): 519-528
http://www.jem-journal.com/article/S0736-4679(16)30175-5/references
Verschoof MA, Zuurbier CCM, de Beer F, et al. Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis. Journal of Neurology 2018; 265(2): 315-321
https://link.springer.com/article/10.1007/s00415-017-8701-y
Chenoweth JA, Gaona SD, Faul M, et al. for the Sacramento County Prehospital Research Consortium. Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma. JAMA Surg 2018; 153(6): 570-575 Published online February 14, 2018
Bellal J, Sadoun M, Aziz H, et al. Repeat Head Computed Tomography in Anticoagulated Traumatic Brain Injury Patients: Still Warranted. The American Surgeon 2018; 80(1): 43-47 January 2014
Ganetsky M, Lopez G, Coreanu T, et al. Risk of Intracranial Hemorrhage in Ground-level Fall With Antiplatelet or Anticoagulant Agents. Academic Emergency Medicine 2017; 24(10): 1258-1266
http://onlinelibrary.wiley.com/doi/10.1111/acem.13217/full
Print “Delayed CT Scan in the Anticoagulated Patient”
August 28, 2018
Thought You Discontinued That Medication? Think Again
In our February 2018 What's New in the Patient Safety World column “10 Years on the Wrong Medication” we noted a case in which a patient was inadvertently continued on a wrong medication for 10 years! That case illustrated how the medical record (either electronic or paper) can propagate medication errors over a long run and that medication reconciliation is not infallible (since several opportunities to identify this error failed to do so). It also emphasizes the need for regular comprehensive reviews of medication regimens (such as the annual “brown bag” review) the need for a communication other than a discharge summary or letter in order to ensure that an incorrect or unnecessary medication is not restarted.
In our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications” and our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!” we highlighted what we consider to be a major flaw in current e-prescribing systems, namely that they do not put the same emphasis on stopping medications as they do on starting them.
But now we find out that medications often get inappropriately continued even after they have been discontiniued in CPOE and e-prescribing systems!
In our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications” we discussed a study done in a large multispecialty group practice in Massachusetts (Allen 2012) which showed that, among targeted medications that were electronically discontinued (on the practice’s EMR), 1.5% were subsequently dispensed by a pharmacy at least once. And this was just at the practice’s internal pharmacy. How often this happened at community pharmacies was not known. Moreover, when they did manual chart reviews of selected high-risk medications that had been discontinued they found that 12% of cases (50 cases) were associated with potential harm. The latter cases included clinical reactions (n = 18), laboratory abnormalities (n = 17), duplicated medication classes dispensed (n = 8), and potential allergic reactions (n = 7). The authors noted that when a physician discontinues a medication on an EMR he/she often (erroneously) assumes that such information is being transmitted to the pharmacy. Such is seldom the case with today’s EMR systems. Further, many pharmacies today have sophisticated systems that let you know, as a patient, that you have a refill waiting for you at the pharmacy. Patients may erroneously presume that their physician restarted that medication.
Now a new study (Copi 2018) looked at a year’s worth of electronic prescriptions for hypotensive, hypoglycemic, anticoagulant, antiplatelet, and statin medications picked up from 3 outpatient pharmacies within the health system. Prescriptions must have been written by a Michigan Medicine health system provider and were excluded if they were written, faxed, or phoned in. They were able to determine the temporal relationship of the order for discontinuation and the pharmacy dispensing by comparing timestamps. They found that 4.94% of over 10,000 prescriptions were picked up at the pharmacies after the prescription order was discontinued in the HER. The prescription was discontinued before final pharmacist verification for 54.56% of those prescriptions. Inadvertently dispensed prescriptions may have contributed to hospital admission 30 days after pick-up for 3 individual patients.
Copi et al. note that electronic message transmission systems to relay changes or cancellations in prescriptions from the prescriber to the pharmacy do exist and may even allow prescribers to send messages to the pharmacy for prescriptions that were handwritten, not just electronically prescribed, But the prescriber must know which pharmacy filled the handwritten prescription and both the EHR and pharmacy dispensing software must be compatible with this function and activate it for this transmission to be useful.
Much like the previous study, the pharmacies in this study were part of the health system. Therefore, the pharmacists had access to the system’s EMR. That health system has now asked all its outpatient pharmacists to perform a check of the patient’s current medication list to ensure that the prescriptions being filled are still active and accurate in the EMR. But the authors recognize that such would only have the potential to catch about 50% of the errors that were observed, because about 50% of these prescriptions were discontinued before the pharmacist verification step. They acknowledge that such check of the EMR also adds an extra step to the pharmacist workflow, and may add considerable time. We all know that time pressures are one factor that significantly increases the risk for errors in pharmacies. They note that pharmacy technicians might be used to participate in medication reconciliation. They also note that inclusion of a pharmacist in the interdisciplinary discharge planning meetings could facilitate letting the outpatient pharmacies know about medication discontinuations.
We always advise patients to keep a list of their current medications with them. That obviously requires frequent updating of the medication list, not only to include new medications but also to exclude discontinued medications. Pharmacists at the outpatient pharmacies should review those updated lists with their own lists of the patients’ medications.
The problem is likely even worse when you consider that most community pharmacies are not integrated into health systems. Some community-wide health information exchanges (HIE’s) or regional health information organizations (RHIO’s) do provide electronic linkages between the health systems, hospitals, and pharmacies but these are not universal. The problem is also amplified when you consider that patients may be receiving medications at more than one pharmacy or from an online pharmacy. Online pharmacies, chain pharmacies, and community pharmacies are often contacting patients by multiple means (phone, email, smartphone apps, etc.) to remind them to refill their medications. So the problem may be even more widespread that in the Allen or Copi studies.
Of course, there is another significant issue that arises when you discontinue a medication. In our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications” we highlighted what we consider to be a major flaw in current e-prescribing systems, namely that they do not put the same emphasis on stopping medications as they do on starting them. In that column we noted a case report in the Medical Journal of Australia (Tong 2014) in which discontinuation of one medication led to excessive levels of a different medication because there had been a drug-drug interaction. Most systems are not programmed to generate any alerts at the time you discontinue a medication. Even if your system would have generated a drug-drug interaction alert when you first prescribed a medication, it would not likely generate an alert later when you discontinue that medication. If such a drug-drug interaction had been active, the discontinuation of one medication may raise or lower the blood levels or effectiveness of the other medication.
We once again highlight a critical issue: stopping a medication is much different than starting one. Starting a medication requires an active process – you either write a prescription, enter one into a computer, or call the pharmacy. You are usually in a situation where you can utilize an electronic order system (CPOE or e-prescribing tool) and you may have access to the many clinical decision support tools in those systems. But discontinuing a medication is often more passive – you might get a call from your patient after hours and just tell the patient over the phone to stop it when the patient tells about a potential side effect. You don’t call the pharmacy to stop it. And, if there was no associated office visit, you might even forget to update the patient’s medication list in your EMR (or paper records) until the patient’s next office visit.
With today’s integration of the EMR to the physician’s smartphone, almost all opportunities to do e-discontinuation should be done with a formal process that should include more than just the discontinuation order. The EMR system could ask “Have you notified the patient to discontinue the medication?”, “What is the reason for the discontinuation?”, and “Do you wish to notify the patient’s pharmacy of the discontinuation?”. The system’s clinical decision support tools should then also consider whether any drug-drug interactions might be in play that would necessitate changing the dosage of another medication.
And don’t forget there is one other mechanism by which discontinued medications get inappropriately continued. Our February 28, 2017 Patient Safety Tip of the Week “The Copy and Paste ETTO” reminds us how the copy/paste function in today’s healthcare IT systems can lead to erroneous medication lists that might result in a patient being inappropriately restarted on a medication that had actually been discontinued.
Lastly – back on our soapbox! Just as we have advocated for inclusion of the indication for new prescriptions, it is important that we always somehow record why we have discontinued a medication. How often have you suggested a medication and your patient says “yes, I was on that medication once" but can’t tell you why they were taking it or why it was stopped. Was it simply not effective (for whatever indication it was prescribed, which may not even be the reason you are now recommending it) or was it stopped because of some unwanted effect? And was the unwanted effect an allergic response, idiosyncratic response, an anticipated side effect, or simply a dose-related side effect. It’s very important to have details available about the reasons for discontinuation. Also, as we noted above, medications are often discontinued at times when a physician or other prescriber may not have access to the EHR or e-prescribing system. Often they get a phone call from a patient and tell them over the phone to stop the medication and then forget to record that in the patient record.
These examples highlight the continuing struggles we have in optimizing medication reconciliation. The need to do medication reconciliation at every office, clinic, hospital, or pharmacy visit is obvious. While we need to rely on technology vendors and HIE/RHIO’s to come up with some better electronic and interoperability solutions, you also need to look at your own practice. How do you update your patients’ medication lists after you do that over-the-phone medication discontinuation? How do you let the pharmacy know you have stopped a medication? How do you find out if your patient is still being dispensed a discontinued medication? How do you find out that another physician has discontinued a medication on one of your patients? And how do you recognize that the medication you’ve discontinued may have had a drug-drug interaction with another medication (the dose of which you may now need to adjust)? Lots of questions. Still no easy answers.
References:
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012; 157(10):700e705
Copi EJ, Kelley LR, Fisher KK. Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes. J Am Pharm Assoc 2018; 58(suppl 4): S46-S50
https://www.japha.org/article/S1544-3191(18)30186-9/fulltext
Tong EY, Kowalski M, Yip GS, Dooley MJ. Impact of drug interactions when medications are stopped: the often forgotten risks. Med J Aust 2014; 200 (6): 345-346
Print “Thought You Discontinued That Medication? Think Again”
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin?
For several years we’ve struggled with the conundrum of the 12-hour nursing shift. On the “pro” side there are fewer handoffs, many nurses like the flexibility of work hours and longer periods of off-time, and nurse administrators often like the flexibility it offers in scheduling.
Multiple studies, discussed in our prior columns, have described the negative effects of 12-hour shifts on nurse health, well-being, and job satisfaction. In our September 29, 2015 Patient Safety Tip of the Week “More on the 12-Hour Nursing Shift” we noted another RN4CAST study that provides insight into the impact of 12-hour shifts on nurse well-being (Dall’Ora 2015). Those researchers found that, while all shift lengths greater than 8 hours were associated with more nurse adverse outcomes, nurses working shifts ≥12 h were more likely to experience burnout, have emotional exhaustion, depersonalization, and low personal accomplishment. Moreover, they were more likely to have job dissatisfaction, dissatisfaction with work schedule flexibility, and report intention to leave their job due to dissatisfaction. Nurses working shifts of 12 hours or more were 40% more likely to report job dissatisfaction and 29% more likely to report their intention to leave their job due to dissatisfaction.
In our July 11, 2017 Patient Safety Tip of the Week “The 12-Hour Shift Takes More Hits” we discussed a study by Ball and colleagues (Ball 2017a), using survey data from the RN4CAST study, which showed the odds of poor quality care were 1.64 times higher for nurses working ≥12 hours. And rate of “care left undone” was 1.13 times higher for nurses working ≥12 hours. In addition, job dissatisfaction was higher the longer the shift length, with nurses more than 50% more likely to report job dissatisfaction when working 12-hour shifts compared to 8-hour shifts.
The care left undone finding is particularly bothersome. In our May 9, 2017 Patient Safety Tip of the Week “Missed Nursing Care and Mortality Risk” we noted a striking finding in a previous study by Ball (Ball 2017b) that a 10% increase in the amount of care left undone by nurses was associated with a 16% increase in mortality. While that study focused more on overall nurse staffing levels and care left undone, the current Ball study suggests that care left undone is a significant problem with 12-hour shifts and one might assume that same effect on mortality rates might apply.
Many of the previous studies relating shift length to nurses’ health have relied upon survey responses or other subjective data. Recently, however, researchers were able to analyze objective data relating sickness absence and shift duration for registered nurses and health care assistants (Dall’Ora 2018). Results were striking: when more than 75% of shifts worked in the previous 7 days were 12 hours in length, the odds of both a short‐term and long‐term sickness episode were increased compared with working none (respective adjusted odds ratios 1.28 and 1.22). Occasional shifts of 12 hours or more (<25%) in the past 7 days were not significantly associated with more sickness absence. But when staff worked a higher proportion of shifts of 12 hours or more, sickness rates increased, with the highest odds for those working more than three quarters of their shifts as 12 hours or more shifts. The authors conclude that routine implementation of long shifts should be avoided.
The scales have been progressively tipping against the use of the 12-hour nursing shift. The downsides on both patient care and the personal health of our valued staff now appear to negate any perceived value of more flexibility.
The current Dall’Ora study certainly dampens some of the enthusiasm generated by earlier studies. A study done in New York City hospitals (Stone 2006) showed that nurses working 12-hour shifts were more satisfied with their jobs, had less emotional exhaustion, and less absenteeism than nurses working 8-hour shifts, all without impacting patient outcomes. One key element to worker satisfaction with 12-hour shifts seems to be how the change was developed and implemented. Where workers had a voice in developing the system, rather than having it imposed on them, satisfaction levels are much higher. But most subsequent studies have tended to show less satisfaction, more burnout, and more absenteeism with the longer shifts.
In our July 11, 2017 Patient Safety Tip of the Week “The 12-Hour Shift Takes More Hits” we even questioned the value of the other “pro” argument for 12-hour shifts: fewer handoffs. Quite frankly, we don’t know if handoffs are well done after 12-hour shifts. Do we allow enough time to do adequate handoffs between those 12-hour shifts? Moreover, there is probably less time available for educational activities when 12-hour shifts are being used. And we don’t know how 12-hour shifts impact team building or social support issues.
Unfortunately, nursing shortages are one of the drivers of use of longer shifts. We’ve speculated that longer shifts due to “mandatory” overtime may be even more detrimental to patient care and nurses’ personal health. And we’ve made strong arguments that factors other than shift length are extremely important. While nurse:patient staffing ratios are important, we made the argument in our May 29, 2018 Patient Safety Tip of the Week “More on Nursing Workload and Patient Safety” that nursing workload may not be adequately reflected in those ratios and that nursing workload is probably a much more important factor influencing both patient care and nurses’ personal health.
We doubt the debate will end here. But the new study by Dall’Ora and colleagues (Dall’Ora 2018) should make healthcare organizations take an even more critical look at their approaches to scheduling nursing shifts.
Our previous columns on the 12-hour nursing shift:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
February 2011 “Update on 12-hour Nursing Shifts”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
September 29, 2015 “More on the 12-Hour Nursing Shift”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
May 29, 2018 “More on Nursing Workload and Patient Safety”
References:
Dall’Ora C, Griffiths P, Ball J, Simon M, Aiken LH. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open 2015, 5: doi:10.1136/bmjopen-2015-008331, published 23 August 2015
http://bmjopen.bmj.com/content/5/9/e008331.full.pdf+html
Ball J, Day T, Murrells T, et al. Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures. BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017
Dall’Ora C, Ball J, Redfern O, et al. Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study. J Nursing Management 2018; 5 July 2018
https://onlinelibrary.wiley.com/doi/abs/10.1111/jonm.12643
Stone PW. Du Y, Cowell R, et al. Comparison of Nurse, System and Quality Patient Care Outcomes in 8-Hour and 12-Hour Shifts. Medical Care 2006; 44(12): 1099-1106
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September 11, 2018
Lessons from a Surgical Fire
We often lament the fact that in healthcare we seldom share root cause analyses (RCA’s) or results of investigations of adverse events. These are excellent learning tools. The California Department of Public Health periodically releases statements of deficiency and plans of corrections for hospitals under its purview. These often have valuable lessons learned that need to be shared with other hospitals. So we sometimes will include cases from the CDPH releases as learning tools. There is no intent to demean the hospitals. The events that occurred have the potential to be repeated at many other hospitals and the goal is to decrease the likelihood of such occurrences.
In the most recent batch of CDPH releases there was one example of a surgical fire that has several lessons we all can learn from (CDPH 2018). The patient was having a lipoma removed from the right side of the forehead. The surgeon discussed with the patient the different methods of anesthesia, including the risk of fire if general anesthesia with endotracheal intubation was not used. The patient apparently indicated he “wants local with monitored anesthesia·care (MAC) only… and will take general anesthesia only if needed as a last choice”. So the patient, surgeon, and anesthesiologist agreed to MAC.
During the timeout the team did discuss fire risk and noted this was a Level 3 (highest) risk, based on what most of you will recognize as the Christiana Fire Risk Assessment Score, which assigns one point for each:
They also pointed out the location of saline that was readily available in the event of a fire.
The procedure was performed under MAC. Oxygen was delivered at 5 liter a minute per face mask. The anesthesiologist used a mask and not a nasal cannula since the patient was “a large guy and might need more oxygen than a nasal cannula can deliver”. When the patient moaned and moved his arms as the incision was made, additional Propofol was given.
When the surgeon started cauterizing a vessel with the electrosurgical unit (ESU or Bovie), he noted a spark occurred, with ignition of the patient’s hair. This was extinguished with gauze (gauze soaked in saline). However, the nurse and surgical tech noted smoke emanating from under the drapes. The nurse saw smoke, pulled the drapes off, and called for help. The surgeon removed the face mask and the anesthesiologist turned off the oxygen. The drapes were completely removed. No active fires were noted under the drapes. Moist lap packs were then placed over the patient’s face and neck area.
The patient suffered second and third degree burns on the left side of the face and neck and eyelashes and eyebrows were affected on both sides. The burns were immediately attended to and the patient subsequently went on to receive skin grafting to burned areas,
The intensity setting of the ESU (Bovie) was set at 35/35. The facility apparently normally sets the intensity at 20-30 for a procedure on the face. The surgeon’s preference card, which apparently was not checked prior to the case, calls for an intensity 30/30. The usual practice at that facility was for the circulating nurse to check the preference cards prior to surgery, then plug in the ESU and set the intensity when the case starts.
So what are the lessons? First, most cases of surgical fires involve procedures above the xyphoid. In a recent PPSA (Pennsylvania Patient Safety Authority) review (Bruley 2018), of 33 surgical fires reported to the PPSA over a 6-year period, 5 involved the scalp, 14 the face, and 4 the neck.
Second, the case reinforces a point we have often made – surgical fires are now most often occurring during what would be considered relatively “minor” procedures (eg. temporal artery biopsies, plastic procedures, or removal of skin lesions on the head/neck). We speculate there may be a couple reasons for that. One is that we probably “let our guard down” in dealing with such procedures, thinking they are simple procedures where little can go wrong. The other is that in such cases there may be no need for supplemental oxygen, yet supplemental oxygen is sometimes routinely provided. In others, use of supplemental oxygen is not anticipated but something occurs during the procedure that leads to its use.
The focus of the hospital’s POC (Plan of Correction) in the CDPH report was on the intensity setting of the ESU:
We previously discussed many issues related to electrosurgery unit safety in our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burn”.
Of course, we don’t know what else was discussed in the hospital’s actual RCA. All we know is what was in the CDPH SOD (statement of deficiencies) and the hospital’s POC (plan of correction).
But, while we agree the intensity setting of the ESU should be set at the lowest necessary level, that would certainly not have been our main focus in doing an RCA on this case. In our opinion, the most salient issue is the use of a heat source in the presence of a open oxygen source. In cases like this, there must be timely coordination between the surgeon and anesthesiologist such that the oxygen is turned off prior to any use of the ESU and enough time is allowed to lapse for oxygen to dissipate from the area where the ESU will be used. The AORN guideline recommends, when an open oxygen source is being used, stopping supplemental oxygen for 1 minute before using an ESU or other heat source.
And since we are discussing oxygen, keep in mind that only the lowest necessary concentration and flow of supplemental oxygen should be used. Many patients don’t need any supplemental oxygen at all. But if they do need it, the concentration and flow should be determined by pulse oximetry.
A second issue has to do with the fact that fire occurred under the drapes. That suggests one of two possibilities. First consideration would be that oxygen had accumulated under drapes that had been improperly placed. Drapes should be “tented” to allow free air flow. The AORN guideline actually also recommends delivering 5 to 10 L/minute of medical air under the drapes to flush out excess oxygen via a second delivery system.
The second consideration might be that a flammable skin prep had been used and had either pooled or had insufficient time for drying. We’d also want to know if an appropriate-sized skin prep applicator had been used. We’ve done several columns discussing the fire risk that occurs with use of the 26-ml applicator in head/neck cases (see our January 10, 2017 Patient Safety Tip of the Week “The 26-ml Applicator Strikes Again!”).
It’s also worth noting that several of the OR personnel in this case never saw actual fire, but rather heard a “sound”. That is not surprising. Sometimes the episode occurs so rapidly that flames are not seen. It’s actually common for personnel to hear a “pop” or a “whoosh” as the only indication a surgical fire has occurred.
When we do an RCA (root cause analysis) on any case, we always make sure to look not only at what went wrong but also at what was done correctly. In this case there were several things done appropriately:
We recommend that a fire risk assessment be done both during the presurgical “huddle” and as part of the surgical “timeout”. We continue to promote use of the SF VAMC Surgical Fire Risk Assessment Protocol, developed at the San Francisco VA as part of an effort to promote fire safety in the OR (Murphy 2010). and which can be embedded into your safe surgery checklist. But the Christiana Fire Risk Assessment Score or the AORN Fire Risk Assessment Tool are equally appropriate.
What should be asked during the timeout when the fire risk is deemed to be high?
We think you will find the AORN Fire Risk Assessment Tool Instructions to be your most important document since it spells out in detail all the steps that need to be taken when you have determined there is substantial risk for a surgical fire.
Fortunately, the incidence of surgical fires appears to be declining, according to the Pennsylvania Patient Safety Authority (Bruley 2018). This likely is due to the increased attention by numerous organizations over the past decade.
We hope you’ll look at the many useful recommendations in our previous columns (listed below). And, of course, we again refer you to the valuable resources on surgical fires provided by ECRI Institute, AORN, the FDA, Christiana Care Health System and the APSF.
Our prior columns on surgical fires:
References:
CDPH (California Department of Public Health). Complaint Intake Number: CA00455976. CDPH 2018
Bruley ME, Arnold TV, Finley E, et al. Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts. Pa Patient Saf Advis 2018 Jun;15(2).
http://patientsafety.pa.gov/ADVISORIES/Pages/201806_SurgicalFires.aspx
SF VAMC Surgical Fire Risk Assessment Protocol
https://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 3
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Christiana Fire Risk Assessment Score
AORN Fire Risk Assessment Tool
AORN Fire Risk Assessment Tool Instructions
AORN (Association of periOperative Registered Nurses). AORN Fire Safety Tool Kit.
Accessed September 3, 2018
ECRI Institute. Surgical Fire Prevention.
https://www.ecri.org/surgical_fires
Christiana Fire Risk Assessment
https://christianacare.org/forhealthprofessionals/education/fireriskassessment/
FDA (US Food & Drug Administration). Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication. FDA Safety Communication 2018; May 29, 2018
APSF (Anesthesia Patient Safety Foundation). Resources. Fire Safety Video. Prevention And Management Of Operating Room Fires.
http://www.apsf.org/resources/fire-safety/
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September 18, 2018
More on Hospital Suicides
Suicide in hospitals has been a frequent topic in our Patient Safety Tips of the Week. Since our last column on this topic, there have been several published cases with lessons learned plus a timely review of the prevalence of hospital suicides.
There has been some debate over the prevalence of hospital suicides in the past. The Joint Commission, in its Sentinel Event Summary Statistics, has noted hospital suicides have remained relatively stable at an average of about 90 per year (range 84-98) from 2014 to 2017. But, since not all hospitals have reported completely to the Joint Commission, those figures are likely an underestimate.
Now, a recent study (Williams 2018) uses reliable data to provide good current estimates. Those researchers added to the Joint Commission Sentinel Events reports data from 27 states reporting to the National Violent Death Reporting System (NVDRS) for 2014-2015. They found that 73.9% of these suicides occurred during psychiatric treatment. They estimate that between 48.5 and 64.9 hospital inpatient suicides occur per year in the United States. Of these, 31.0 to 51.7 are expected to involve psychiatric inpatients. Many of our prior columns have focused on the 26% that attempt or commit suicide when housed in locations other than behavioral health units.
In the Williams study (Williams 2018), hanging was by far the most common method for suicide in the hospital, accounting for about 70% of cases in both databases when a method was specified. Over 50% of the sentinel event suicides occurred in the bathroom.
Our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” discussed several cases of inpatient suicides occurring in bathrooms and highlighted many contributing factors, with recommendations to mitigate risks. Two recent published cases also reinforce the need for attention to suicide risks in the bathroom. In one (Glathar 2018) a patient hanged himself from the top hinge of a shower door (the case had other issues, such as staff failing to carry out 15-minute observations). In another case (Mills 2018), a patient who had cut both of her forearms with a kitchen knife in a suicide gesture, had her forearm laceration sutured and bandaged with gauze padding. She was then transferred to the inpatient psychiatric unit. There, she asked to use the bathroom, where she unwrapped the gauze bandage from her wrist, wrapped it around her neck and over the shower bar in the bathroom, and attempted to hang herself. Fortunately, staff heard a noise and responded and were able to cut the gauze before any serious injury occurred. (By the way, while we always recommend removing things like belts and shoelaces from patients on behavioral health units, who would have thought about the gauze bandage as a tool for suicide?).
We’ve discussed the VA’s Mental Health Environment of Care Checklist (MHEOCC) in many of our columns. That checklist is available online on the VA Patient Safety website, as is an excellent video narrated by Peter Mills, MD. In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
One very pertinent question asked in the MHEOCC is “Are doors that are within rooms and that open to other in-room areas such as bath/shower/toilet areas (i.e., not corridor doors) designed to eliminate anchor points?”. But keep in mind that almost any type of solid door might be used as an anchor even if it lacks latches, hooks, or other obvious loopable items. One could still conceivably loop bedsheets or clothing over the top of a solid door even if it has a “sloped” surface. Therefore, the MHEOCC recommends soft break-away doors for bathrooms and showers.
In our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” we recommended the following:
But it’s not enough to just ensure that bathrooms on your inpatient behavioral health unit meet the MHEOCC standards. Consider that the potentially suicidal patient on an intrahospital transport, such as a trip to the radiology suite, may lock him/herself in a bathroom in that suite and there are a number of loopable items in those bathrooms. You’ll recall that in our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt” we included the items below as ones to search for in your patient safety scavenger hunt:
And, speaking of intrahospital transports, don’t forget to the specific risks for wandering, elopement and/or suicide on your “Ticket to Ride” checklist for intrahospital transports (see, for example, our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport”). Suicide risk should be considered when patients are transported to Radiology (or other sites) whether the patient is on a behavioral health unit or medical unit (see our prior columns January 6, 2009 “Preventing Inpatient Suicides”, February 9, 2010 “More on Preventing Inpatient Suicides” and December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”).
Two recent California Department of Public Health reports also illustrate other risks during transports or transfers from one unit to another. In one (CDPH 2018a), a patient was sent to ED from a psychiatry unit, eloped from the ED, and was hit by a car. In the other (CDPH 2018b), a suicidal patient was being transferred back from the ED to a psychiatric unit, jumped up and ran away and jumped 25-40 feet from a building, suffering skull and spine fractures and numerous other fractures and body trauma. He survived but had a long hospitalization, multiple procedures, and multiple deficits. During the transport, the patient had been accompanied by a nurse assistant who had no training in managing suicidal patients and two security guards who were not authorized to restrain patients. They called local police but it was too late to prevent the jump from the building.
In the Williams study (Williams 2018), when a method of suicide was specified, 6-10% of the suicides involved jumping from heights. Several of our columns have discussed patients who jump from windows and we’ve noted features that are common to such incidents (see our Patient Safety Tips of the Week for April 12, 2016 “Falls from Hospital Windows”, February 14, 2017 “Yet More Jumps from Hospital Windows”, and July 10, 2018 “Another Jump from a Hospital Window”). These are typically patients who are being housed on general medical or surgical units and there is a a pattern evolving. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically he/she is confused or hallucinating. It’s not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room.
In these cases, patients were able to stand up on the bed and “launch themselves” through the window from the bed. That implies a proximity of the bed to the window. So one key lesson is to position the patient’s bed in the room at a reasonable distance away from the window so such “launches” are not possible.
Second, positioning of the observer may be important. The observer is usually positioned in the room on the side away from the window and near the door. We suspect that is intentional and may be a consideration for the safety of the observer plus it would allow the observer to easily yell for help if necessary. But that obviously needs to be rethought.
And some other less obvious equipment needs to be removed: the second bed in a 2-bed room should probably be temporarily moved. That can only hinder someone from attempting to rescue a patient who is trying to jump out of a window.
And since the patient often uses an object in the room to break the window, such as a chair or piece of medical equipment, care must be taken to make sure such objects are not in reach for a patient even for a very brief time. For example, if the observer needs to briefly leave the room perhaps the chair should be removed.
In our October 6, 2015 Patient Safety Tip of the Week “Suicide and Other Violent Inpatient Deaths” we noted that another potential vulnerability has to do with fire alarms. In one case a patient pulled a fire alarm which automatically unlocked doors on a behavioral health unit, allowing him to escape and jump to his death from a rooftop (Pfeiffer 2010). After we heard about that case we began to include inspection of stairwells and rooftop access points adjacent to behavioral health units in our patient safety walkrounds or environmental walkrounds.
Another recent case did not involve an actual suicide but serves as a reminder of how patients may use fire alarms to facilitate elopement (Fettes 2018). A patient on a behavioral health unit set his mattress and bedding on fire, triggering the facility's fire alarm. The alarm automatically disarmed the facility's fire doors and the patient left the unit. Fortunately, he was later found and returned to the unit. But the case illustrates a problem we’ve seen before. The behavioral health unit involved did not have a specific policy for "a combined fire and security incident". You’ll recall we have recommended that facilities consider combining safety drills to account for such incidents. For example, you could do a fire drill and then immediately do a drill for a missing patient (or an abducted child).
Since several cases mentioned in today’s column have also involved the emergency department, it is worth noting a recent study on improving documentation of suicide risk factors in the ED (Reshetukha 2018). The researchers did an educational intervention on suicide for all emergency medicine and psychiatry physicians. This was followed by the placement of a suicide risk assessment prompt within local ED’s. Documentation of 34/40 and 33/40 suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Another recent study also emphasized chronic pain as a significant risk factor in 10% of suicides (Petrosky 2018). While a wide variety of causes for chronic pain were noted, the most common were related to back pain, cancer, and arthritis, all common in patients seen in the ED.
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
See our previous columns on wandering, eloping, and missing patients:
References:
The Joint Commission. Sentinel Event Summary Statistics.
https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf
Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and Method of Suicide in Hospitals in the United States. Jt Comm J Qual Patient Saf 2018; Published online September 3, 2018
https://www.jointcommissionjournal.com/article/S1553-7250(18)30253-8/fulltext#cebibl1
Glathar B. Failed patient checks linked to suicide at Wyoming State Hospital.
Uinta County Herald 2018; September 12, 2018
Mills PD. Web M&M. Suicide Risk in the Hospital. AHRQ PSNet 2018; May 2018
https://psnet.ahrq.gov/webmm/case/445
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
video
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
CDPH (California Department of Public Health). Complaint Intake Number: CA00479941; CDPH 2018
CDPH (California Department of Public Health). Complaint Intake Number: CA00462955; ; CDPH 2018
Pfeiffer R. Man survives plunge from roof of hospital. Niagara Gazette 2010; October 17, 2010
Fettes J, Scott E. Patient escapes from Canberra Hospital's mental health unit by starting fire, disarming fire door. ABC (Australia) News 2018; Posted 29 Aug 2018
http://www.abc.net.au/news/2018-08-30/mental-health-patient-escapes-canberra-hospital/10179584
Reshetukha TR, Alavi N, Prost E, et al. Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt. General Hospital Psychiatry 2018; 52: 34-40
https://www.sciencedirect.com/science/article/pii/S0163834317303183
Petrosky E, Harpaz R, Fowler KA, et al. Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System. Ann Intern Med 2018; Epub ahead of print 11 September 2018
Print “More on Hospital Suicides”
September 25, 2018
Foley Follies
One of the most frustrating things in patient safety is when we fail to improve despite a robust evidence base for best practices. One of the conditions for which we have such a robust evidence base is the catheter-associated urinary tract infection (CAUTI).
Way back in the early 1990’s we used a simple chart sticker to get a 50% reduction in unnecessary urinary catheters (see our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”). Then we saw further reductions once we began to use clinical decision support built into our electronic medical records. Other useful measures have included daily “huddles” or “catheter rounds”, nurse-led protocols, automatic discontinuation orders, and flagging catheter duration in the EMR. Especially helpful has been suggesting alternatives to indwelling catheters (eg. condom catheters in males, use of bladder ultrasound to determine bladder volume). A major step was when clinicians from the University of Michigan (Meddings 2015) published appropriateness criteria for urinary catheters (see our June 30, 2015 Patient Safety Tip of the Week “What Are Appropriate Indications for Urinary Catheters?”). After that, more hospitals began auditing practices to ensure that catheter use was in line with appropriateness.
But CAUTI’s haven’t disappeared. In fact, the latest AHRQ data on hospital acquired conditions show that CAUTI’s actually increased in recent years (AHRQ 2018). And Medicare stopping reimbursement for hospital-acquired conditions has had little impact, though changes in coding by hospitals may play a role in that (Calderwood 2018).
Historically, there have been 3 areas in the hospital where urinary catheters are often inserted for dubious reasons (and then often left in for unnecessary durations): the ER, the OR, and the ICU. And the bane of those practicing in the hospital is the “surprise” Foley catheter (see our Patient Safety Tip of the Week for May 8, 2007 “Doctor, when do I get this red rubber hose removed?” and our July 2016 What's New in the Patient Safety World column “Holy Moly, My Patient has a FOLEY!”). This is when, unbeknownst to the attending physician, his/her patient has a Foley catheter inserted during the evening or night and its presence is not readily recognized.
Our June 2013 What's New in the Patient Safety World column “Barriers to CAUTI Prevention” highlighted the barriers to implementation of best practices to prevent CAUTI’s seen in the highly successful Keystone initiative in Michigan to prevent CAUTI’s (Krein 2013). Not surprising was lack of buy-in from physicians and nurses, or insertion of the catheter in the ER. A surprising barrier, however, was requests from patient or family for the catheter.
While many guidelines and protocols call for timely postoperative removal of urinary catheters placed prior to surgical procedures, there has been a lack of guidelines to help determine in which procedures a catheter is needed at all. We recall working with a small hospital that had only two general surgeons. One routinely used a urinary catheter during appendectomies, the other did not. Once we pointed out the discrepancy, the other surgeon realized he did not need a catheter when doing a routine appendectomy.
Now, the Michigan group (Meddings 2018) has again come to the rescue! They have developed guidelines for patients undergoing general and orthopedic surgery. Procedural appropriateness ratings for catheters were summarized for clinical use into three groups:
Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures. You’ll have to go to the article itself for details about the individual procedures. But the first category (no need for a catheter) includes things like laparoscopic cholecystectomy, open appendectomy, most hernia repairs, and unilateral knee and hip procedures. Examples of procedures where removal of the catheter before the patient leaves the OR include bilateral hip and knee procedures, hip replacement revision surgery, and several bariatric procedures. Lastly, the category where catheter use for at least one post-op day is appropriate includes procedures like colectomies and abdominoperineal resections.
And, while we have focused on CAUTI prevention, don’t forget there are many other reasons to avoid unnecessary use of Foley catheters. The Michigan group, again, has recently published an analysis of the various complications of indwelling urinary catheters (Saint 2018). 71% of the patients were male (largely because some of the hospitals studied were VA hospitals). 76% had the catheter removed within 3 days of insertion. Almost 80% of the patients studied had short-term catheters placed for surgical procedures. Noninfectious complications were 5 times more frequent than infectious ones.
57% of patients reported at least 1 complication due to the indwelling urethral catheter over the 30 days of followup. Infectious complications were reported by 10.5% and noninfectious complications (eg, pain or discomfort, blood in the urine, or sense of urinary urgency) by 55.4%.
Pain, discomfort, bleeding, or trauma at the time of catheter placement were noted by only 2% of patients who had the catheters placed for a surgical procedure but by 57% of those who had the catheter placed for bladder obstruction or urinary retention. Leaking urine, urinary urgency or bladder spasms, and difficulty starting or stopping the urine stream were the most common symptoms in those who had their catheter removed. In those who still had catheters in place the most common symptoms were pain, urgency or bladder spasms, or hematuria. Those who still had a catheter also experienced considerable limitation of activities of daily living or restriction of social activities (the old “one-point restraint”). Of those who had their catheter removed, 5% had sexual dysfunction. As you’d expect, longer duration of catheter use was associated with both more infectious and noninfectious complications. Women were more likely to report an infectious complication than men (15.5% vs. 8.6%), a point attributed to the shorter female urethra and closer proximity of perineal bacterial colonization to the insertion site of the indwelling catheter.
In view of the above study, you have even more reason to ensure appropriate use of urinary catheters. We hope that you’ll implement the many interventions we’ve discussed in detail in our numerous columns listed below and mentioned briefly at the beginning of today’s column. Recently, one hospital system implemented many of those interventions in a serial fashion and achieved excellent results (Youngerman 2018). After training on best practices, they standardized electronic documentation. In the second phase, duration of urinary catheter use was tracked in real time. In the third phase, clinicians were prompted by an alert reminding them of catheter duration. And in the final phase, orders for new urinary catheters included automatic expiration and required input of an appropriate indication plus suggestions for alternatives. CAUTI rate per 10,000 patient days decreased incrementally in each phase (from 9.06 in phase 1 to 1.65 in phase 4 or a relative risk 0.182). New catheters per 1,000 patient days declined from 53.4 in phase 1 to 39.5 in phase 4 (RR 0.740) and catheter days per 1,000 patient days decreased from 194.5 in phase 1 to 140.7 in phase 4 (RR 0.723). The reinsertion rate also declined.
Our evidence base to avoid inappropriate use of urinary catheters is very strong. It’s time we apply our knowledge of best practices to reduce their use and avoid both the infectious and noninfectious complications associated with them.
Our other columns on urinary catheter-associated UTI’s:
References:
Meddings J, Saint S, Fowler KE, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 162(9_Supplement): S1-S34
http://annals.org/article.aspx?articleid=2280677
AHRQ (Agency for Healthcare Research and Quality). AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014–2016. AHRQ 2018; June 2018
Calderwood MS, Kawai AT, Jin R, Lee GM. Centers for medicare and medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Infection Control & Hospital Epidemiology 2018; 39(8): 897-901 Published online: 28 June 2018
Krein SL, Kowalski CP, Harrod M, Forman J, Saint S. Barriers to Reducing Urinary Catheter Use: A Qualitative Assessment of a Statewide Initiative. JAMA Intern Med 2013; 173(10): 881-886
http://archinte.jamanetwork.com/article.aspx?articleid=1672274
Meddings J, Skolarus TA, Fowler KE, et al. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Qual Saf 2018; Published Online First: 12 August 2018
https://qualitysafety.bmj.com/content/early/2018/08/11/bmjqs-2018-008025
Saint S, Trakutner BW, Fowler KE, et al. A Multicenter Study of Patient-Reported Infectious and Noninfectious Complications Associated With Indwelling Urethral Catheters. JAMA Intern Med 2018; Published online July 2, 2018.
Youngerman BE, Salmasian H, Carter EJ, et al. Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system. Infection Control & Hospital Epidemiology 2018; 39(8): 902-908 Published online: 13 June 2018
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January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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